Proposition and application of an environmental salubrity index in rural agglomerations

ABSTRACT OBJECTIVE Propose an Índice de salubridade ambiental (ISARural – environmental salubrity index) that expresses the conditions experienced in rural agglomerations, including indicators and subindicators for its subsequent application in rural communities in the state of Goiás. METHODS We developed the research in three phases: 1) previous analysis for the proposition of an ISARural, with the participation of seven specialists; 2) proposition of the ISARural by means of the Delphi method, starting with 168 specialists from 26 federative units of Brazil and Distrito Federal; and 3) application of the ISARural in 43 rural communities in the state of Goiás. RESULTS The proposed ISARural resulted in the composition of eight indicators, four of which related to basic sanitation, and the others to health, socioeconomic conditions, public services offered, and housing conditions. The weight assigned to each indicator ranged from 22.82% for the water supply indicator to 6.35% for the service indicator, it is possible to apply the ISARural fully or to evaluate each indicator individually. The application of ISARural in communities of Goiás classified 86% of them with low salubrity, highlighting the worst conditions for quilombola communities. The sanitary sewage had the lowest score among the ISARural indicators, requiring greater attention from public authorities. CONCLUSIONS This study contributed to the proposition of an index in line with the concept of environmental salubrity, useful in the scope of public policies as a conditioner for the prioritization of actions needed to improve the salubrity conditions identified. The proposed ISARural can be fully applied or used in the individual evaluation of each indicator of its composition. The results of its application made it possible to identify the communities with the worst environmental salubrity conditions and the indicators that require greater priority attention in the communities studied.


INTRODUCTION
Health is the result of living conditions of a population, expressing the social and economic organization of the country, having as determinants and conditioning factors: food, housing, basic sanitation, environment, work, income, education, physical activity, transportation, leisure and access to essential goods and services, among others 1 .
Thus, these basic individual and collective needs promote the environmental salubrity of a population. Internationally, there is no direct concept of environmental salubrity, since the terminology is presented by the expression environmental health, and, in Brazil, differs from the concept of salubridade ambiental (environmental salubrity). In general, papers use the terms health, hygiene and cleaning to address the salubrious issue. In Brazil, environmental salubrity was initially defined by State Law no. 750, of March 31, 1992, in Article 2, Section II, "as the environmental quality capable of preventing the occurrence of diseases transmitted by the environment and of promoting the improvement of mesological conditions favorable to the health of the urban and rural population" 2 . This concept has been undergoing changes, as presented in several publications [3][4][5] .
The study of the environmental salubrity of a place is important to measure the health situation that a certain population enjoys as a result of their living conditions. Therefore, it is possible to measure a healthy environment by determining the health status of a population, influenced by socioeconomic conditions, education, basic sanitation, and the environments in which they circulate daily.
In this context, to determine environmental salubrity, the Conselho Estadual de Saneamento (Conesan -State Sanitation Council) 6 proposed the indicador de salubridade ambiental (ISA -Environmental Salubrity Indicator), from which its original composition has been adapted, with the inclusion and exclusion of indicators and/or subindicators and the alteration of their weights. Many times this occurs arbitrarily or through the replication of existing studies, considering, or not, the peculiarities of the analyzed region [7][8][9] . It is important to select carefully the indicators to compose the ISA, interrelating its problem and objective of analysis. Few studies have used the literature review 10 and employed the Delphi method 11,12 to propose an index.
Despite the good acceptability of ISA, little research exists on environmental salubrity in rural areas. Of 76 studies on the ISA 9 , only seven were applied to rural areas, where only one study adapted the ISA, considering the conceptual relations of sanitation and health. However, the object of study in that case was the rural households, not the rural agglomeration 13 .
Thus, the objective of this work was to propose an index to determine environmental salubrity in rural agglomerations (ISA Rural ) and apply it to rural communities in the state of Goiás.

METHODS
We carried out the research methodology in three phases, preceded by a literature review using the following databases: Scientific Electronic Library Online (SciELO); Periódicos Capes; Web of Science, and other online search tools. For this, we used the keywords in English and Portuguese: "indicator"; "index"; "salubrity"; "environmental health"; "environmental"; "health"; "indicador"; "índice"; "salubridade"; "salubridade ambiental"; "saúde ambiental"; "indicador de salubridade" and "ISA". The material found provided subsidies for the elaboration of the forms used in the first and second phases.

Phase One: Preliminary Analysis to Propose an ISA Rural
We carried out this phase in order to define the methodology to apply for the proposition of an ISA Rural . For this, we selected specialists based on their area of expertise, related to ISA and to environmental indicators or environmental health, in addition to their availability to contribute to the project. Therefore, we chose seven experts who could participate in the activities and be present at a face-to-face activity. In order to guide and bring subsidies for the discussions, we prepared and applied a semi-structured interview form containing: the program, the purpose of ISA, concepts of environmental salubrity, the Basic Manual of ISA 6 , and six guiding questions (in a complementary file) a . After planning the answers, we had a meeting, in Goiânia, on March 20, 2019, when we discussed the topic, culminating with the indication of a method to apply in the proposition of an ISA Rural , besides the initial indicators useful for its composition and the definition of consultation with experts per domain area.

Phase Two: ISA Rural Proposition
We built the ISA proposition using the Delphi method, useful to structure the communication process of a group in such a way that it can, in an integrated way, deal with complex problems 14 . We built it in the following sequence: The meeting in person started with a discussion about the answers of 57.14% of the experts consulted in the first phase. Based on the existing concepts of environmental salubrity and having as main reference the concept currently used by Funasa 5 , we discussed and proposed, together with the specialists who contributed to the study, that "environmental salubrity consists of the health situation that a certain population enjoys as a result of the socioeconomic and environmental conditions in which they live". We used this as a reference for the determination of indicators and subindicators and their weightings.

Selection of Experts
Due to the diversity of the rural environment, we defined the ISA Rural proposition to be for rural agglomerations, and not for all rural areas. The Brazilian Institute of Geography and Statistics (IBGE) defines rural agglomerations as residential units with adjacent buildings, that is, 50 meters or less in distance from each other and with characteristics of permanence 15 . In this sense, ISA Rural can be applied to census sectors:1b, 2 and 4 (agglomerations close to urban areas); 3 (more densely populated isolated agglomerations), 5, 6 and 7 (less densely populated isolated agglomerations), defined in the programa nacional de saneamento rural (PNSR -national rural sanitation program) 16 , one of the three programs of the Plano Nacional de Saneamento Básico (Plansab -National Basic Sanitation Plan) 17 .
By consensus of the experts, we chose Delphi as the most appropriate method, developed in three stages: 1) choice and/or complementation of the indicators suggested in the meeting; 2) evaluation of the indicators, and 3) choice and evaluation of the subindicators. Initially, we suggested seven indicators for the consultation with experts: indicador de abastecimento de água (I AB -water supply indicator); indicador de esgotamento sanitário (I ES -sewage indicator); indicador de resíduos sólidos (I RS -solid waste indicator); indicador de drenagem (I DR -drainage indicator); health indicator (I Health ); indicador socioeconômico (I SE -socioeconomic indicator); and service indicator (I Services ). Finally, we defined that the specialists should be selected and divided by areas of expertise, composing seven groups, four related to basic sanitation, one to environmental health, and two others to environmental management and rural communities. The last two groups have the function of allowing the analysis of the composition of the indicators and revealing, by the representatives of the communities, the particularities and limitations of the rural areas. Thus, the previous analysis phase fulfilled the task of defining the methodology for the ISA Rural proposition.

ISA Rural Proposition
After the consensus obtained in the previous phase, we began proposing the ISA Rural using the Delphi method, divided in three stages as described in Table 1. It presents the number of invited specialists, the frequency and time of feedback, as well as the UF and the Distrito Federal without feedback, representing, at the end of the ISA Rural composition, 70.4% of participation, which, given the geographical dimensions of the country, was considered excellent.
The frequency of agreement of the seven indicators, defined in the previous analysis and suggested in the 1st and 2nd rounds of selection of ISA Rural indicators (Table 1), is presented in Figure 1, together with the frequency of suggestion of three new indicators suggested in the 1st round and the percentage of agreement of their inclusion. In the 1st round, the indicators I AB , I ES , I RS and I Health obtained 100% frequency of agreement, with only a few exceptions of partial agreement, such as the inclusion of the word "management" in the I RS , changing to indicador de manejo de resíduos sólidos (I MRS -solid waste management indicator). Most experts agreed, totally or partially, with the I DR (89.06%), I SE (98.44%) and I Services (79.69%).
Regarding the I DR , the specialists who did not agree with its inclusion (10.94%) justified that its relevance is only for urban areas, because, for rural areas, drainage is a natural process, and that Federal Law no. 11.455/2007 18 only contemplates urban areas. However, we considered rainwater management in the PNSR 16 indicators. For this indicator, the suggestion is to include the word "management", with reference to the rural sanitation components of the PNSR, changing it to indicador de manejo de águas pluviais (I MAPrainwater management indicator) in place of the I DR . Regarding the I SE , only one expert did not agree with its inclusion, but did not provide any justification. For I Services , the reasons for not agreeing were that it is a very broad indicator, it is difficult to obtain data, and it is included in the previous indicators. In this round, we observed the suggestion of 21 more indicators different from the initial seven, and we considered relevant the one suggested by two or more experts, resulting in three indicators: 1) indicador de condições de moradia (I CM -housing conditions indicator); 2) indicador de energia elétrica (I EL -electric power indicator); and 3) indicador de controle de vetores (I CV -vector control indicator) ( Figure 1).
Also during the 1st round, we separated the subindicators suggested by the specialists into groups that encompassed the same theme. We used those with higher frequency in the proposition of subindicators in the 3rd stage of the Delphi method application. In the 2nd round, we presented all the questions and observations to the experts, with the option of performing a new analysis on the ISA Rural composition. Among the ten suggested indicators, eight presented a frequency greater than 70% of agreement (total and partial), which we maintained and considered for the weighting of the formula. We considered that the other indicators contemplated I EL and I CV , and we removed them from the index. Eight indicators defined the ISA Rural , four related to basic sanitation components, one to health, one to socioeconomic conditions, one to services offered in rural agglomerations, and one to housing conditions. Thus, the following indicators remained: I AB ; I ES ; I MRS ; I MAP ; I Health ; I SE ; I Services ; and I CM .
The sanitation and health indicators accounted for 75.81% of the weight of the ISA Rural .
In the next round, relative to the 2nd stage of the Delphi method application, the experts considered the weights for each one of the indicators, resulting in the following average values and standard deviations for each indicator:      For the 1st round of the 3rd stage of the Delphi method application, and based on the groups of subindicators that obtained the highest percentage of suggestion in the 1st round of the 1st stage, we consulted the specific technical-scientific bibliography, considering the concept of environmental salubrity, used to formulated a list of subindicators sent for consultation to the specialists. Figure 2 shows the frequency of agreement of the inclusion of subindicators in the formulas and the scores.
The subindicators of I AB , I MRS , I SE and I CM obtained 100% frequency of agreement for inclusion, with some reservations of adjustments in the descriptions of the formulas and weightings.
In the I ES subindicators, only two experts (7.1%) did not agree with the inclusion, justifying that it would not be necessary to separate sanitary sewage into excreta and wastewater. However, studies applied in rural areas 13 considered this separation relevant. Therefore, we kept these subindicators for the next round, with only minor changes in the formulas and scores, according to the suggestions.
Regarding I MAP , half of the subindicators (I APV , I IA and I E ) obtained 100% agreement, and the other half obtained 87.5% frequency of agreement for I UV , 91.7% for I CES and 95.8% for I US . The justification was the irrelevance of these indicators, also influencing the answers obtained in the formulas and scores.
As for I Services , only the subindicators I EE and I TP did not obtain inclusion agreement in 100%, with 88.9%. In the descriptions of the formulas, the disagreement (11.1%) occurred in the I E , I S , I EE , and I TP subindicators, among which the suggestion was that the criterion of service attendance was included in the I E and I S subindicators.
The subindicators of I Health , despite having an inclusion concordance of more than 80%, presented several considerations in the formula descriptions. One of them was the modification of the sampling form, from household to inhabitants, obtaining the occurrence of the disease. Because it changes the whole calculation form, we presented the changes suggested for evaluation in the 2nd round of the 3rd stage to the experts. For the other indicators, we present only the subindicator weighting option.
In the last round, we weighted all the subindicators with the average of the assigned weights and also obtained the frequency of agreement of the changes in the formulas of the I Health subindicators. Only one expert disagreed with the home water treatment subindicator (I PTA ); the others fully agreed. Table 2 shows the final formulas for the indicators and their respective subindicators and scores.
When comparing ISA Rural 's final proposition with studies found in the specific bibliography, we found that none of them contemplates, in an integral way, all the indicators. The separation of the specialists by area of expertise brought the formulation of essential subindicators with specificities, requiring easily obtainable data for calculation. Public authorities require some of them by means of PNSR 16 , and it is possible to obtain the others using questionnaires applied and used by the community health agents, improving them, as suggested in Bernardes, Bernardes and Gunther 13 .

ISA Rural application
The application of the proposed ISA Rural has found that only 14% of the communities are of medium salubrity, with the agglomerations occupying five of the top six places.
In the remaining communities (86%), there is low salubrity (Table 3), with 61.9% of the quilombola communities below average.
By formula D raa = number of households in the rural agglomeration supplied by a water distribution network, with indoor plumbing at the residence or on the property, or by a well, water source, or rainwater collection cistern, with indoor plumbing D rt = number of households in the rural agglomeration  (Table 3) obtained for I AB . The low salubrity occurred mainly due to the quality of the water supply, with the presence of E. coli in most of the water samples analyzed, resulting in disagreement with Annex XX of Consolidation Ordinance no. 5 of the Ministry of Health 19 . The presence of E. coli in the water consumed by the population in rural communities has been reported in national and international scientific By formula Basic education in the rural agglomeration (E), criterion: rural agglomeration is served by basic education service (school in the rural agglomeration or availability of school transport to a basic education unit) = 1; rural agglomeration is not served by public education service = 0 Health (I S ) By formula Health in the rural agglomeration (S), criterion: rural agglomeration is served by a health service (health center or community health workers) = 1; rural agglomeration is not served by a public health service = 0 Electric power (I EE ) By formula D rra = number of households in the rural agglomeration with an internal water reservoir (water tank) that is capped and sanitized every six months D rt = number of households in the rural agglomeration with an internal reservoir  16 , and the study by Roland et al. 23 A study conducted in riverside communities in Amazônia concluded that one of the characteristics that most contribute to the situation of insalubrity and low salubrity is the precariousness of the houses in relation to the adequate disposal of excreta and grey waters 13 . Only two communities (4.65%) received the classification of medium salubrity, and another two (4.65%) as low salubrity.
Another worrisome basic sanitation component is solid waste management, represented by I MRS , present in only 6.98% of the communities served, in more than 80% of the households by direct or indirect solid waste collection. Although the great majority of the households in the communities separate their waste, they do not have adequate disposal, and burning is the main form of disposal, similar to the situation presented in the PNSR 16 diagnostic and other studies 24 . The article 47 of the National Solid Waste Policy 25 forbid this practice.
Depending on the composition of the waste, it can release toxic gases, and does not reduce all types of waste, contributing to the proliferation of diseases and influencing the quality of life of the population 23 . In view of the above about the I MRS , 53.49% of the communities fit as insalubrious, 39.53% with low salubrity and 6.98% medium salubrity.
In relation to the I MAP , we classified only the riverside community Arraial da Ponte, representing 2.33% of the analyzed communities, as salubrious. The presence of pavement, curbs, and manholes (a device that allows rainwater drainage) characterized this condition, serving 50% of the community. We classified the others, 76.74% as medium salubrity, and 20.93% as low salubrity. Rainwater management is the only sanitation component for which it was not possible to diagnose the current situation in rural areas of Brazil by PNSR 16 , because IBGE 26 does not have enough data for such an analysis. For this reason, it is one of the biggest barriers to conducting studies on this component of basic sanitation, which stops the proper direction of public policies to solve problems related to infrastructure 23 .
I Health was the third indicator to present the best results in the survey. We verified the salubrious situation registered in 30.2% of the communities and medium salubrious in 69.8%. This is mainly because the inhabitants of the communities have not been diagnosed by a health professional with schistosomiasis and/or leptospirosis, with the exception of one inhabitant of the Julião Ribeiro community, and no deaths of children under one year of age have occurred in these communities. However, many residents of the communities tested positive for hepatitis A, corroborating another study on rural agglomerations in the southwest of Goiás in which 82.20% of the residents had antibodies to the virus 27 , the main factor in the decrease in salubrity in this indicator.
The I SE was the second indicator to present the worst salubrity results. Thus, 48.84% of the communities presented an insalubrity situation and 51.16% presented low salubrity due to the low education and monthly per capita income of the inhabitants. This consolidated the data presented in the PNSR 16 and the analyses that the lower the levels of education and income, the worse the solutions adopted in basic sanitation 28 .
In general, I Services showed the best results, with salubrity of 65.12% of the communities and 34.88% with medium salubrity. This is because 100% of the communities have basic education services, 69.77% have health services, and, in more than 90% of the households, 93% and 62.8% have access, respectively, to electricity and means of communication.
The Programa Nacional de Universalização do Acesso e Uso da Energia Elétrica 29 (National Program for the Universalization of Access to and Use of Electric Energy), responsible for the evolution of the universalization of access to energy, with a deadline of 2022, was extended several times. Therefore, it produces, and certainly will produce, improvements in social and economic dynamics for the communities not yet fully served by this fundamental service 30 .
Finally, the I CM was the second indicator to show the best salubrity results, with 67.44% of the communities in a salubrious situation, 25.58% with medium salubrity, and 6.98% with low salubrity. In general, the communities have houses with adequate walls, floors and roofs, including the bathroom. However, their water reservoirs are in inadequate conditions, which may be one of the factors contributing to the low quality of the water and for being places of contamination 31 .

CONCLUSIONS
The proposed ISA Rural is in line with the concept of environmental salubrity. It is useful in the context of public policies, as a conditioner for the prioritization of actions necessary to improve the salubrity conditions in rural agglomerations, aiming to contribute to the health level of their populations. In addition, it allows an evaluation of the evolution of the goals in the PNSR and the Municipal Sanitation Plan. It is possible to apply this index in its totality or in the evaluation of each indicator that composes it.
The results of the application of ISA Rural in the communities studied in the state of Goiás indicate that the public authorities should devote priority attention to implement actions aimed at the universalization of sanitary sewerage, followed by the improvement of socioeconomic conditions, particularly in quilombola communities, which presented the worst environmental salubrity conditions among the communities studied.